Robotic and laparoscopic total mesorectal excision for rectal cancer: a case-matched study

The role of robotic-assisted surgery in the management of rectal cancer: a systematic review and meta-analysis

BACKGROUND

Rectal cancer poses a significant global health burden. There is a lack of concrete evidence concerning the benefits of robotic-assisted surgery (RAS) for rectal cancer surgery as compared to laparoscopic and open techniques. To address this gap, we conducted a meta-analysis to assess the intraoperative, postoperative, and safety outcomes of robotic surgery in this context.

RESEARCH METHODOLOGY

A search of MEDLINE, Scopus and the Cochrane Library. Randomized and non-randomized studies up to February 2, 2024 comparing robotic surgery versus laparoscopic or open surgery for rectal cancer. The outcomes of interest were operative time, blood loss, harvested lymph nodes, conversion rate, postoperative hospital stay, survival to hospital discharge, urinary retention rate, and anastomotic leakage rate. A random-effects meta-analysis was performed to pool means and dichotomous data to derive weighted mean differences and odds ratios, respectively.

RESULTS

A total of 56 studies were shortlisted after the study selection process with a total of 25 458 rectal cancer patients. From the intraoperative outcomes, RAS was significantly associated with an increased operative time (WMD: 41.04, P <0.00001), decreased blood loss (WMD: -24.56, P <0.00001), decreased conversion rates (OR: 0.39, P <0.00001), lesser stay at the hospital (WMD: -1.93, P <0.00001), and no difference was found in lymph nodes harvested. Similarly, RAS group had a significantly greater survival to hospital discharge (OR: 1.90, P =0.04), decreased urinary retention rate (OR: 0.59, P =0.002), and no difference was seen in anastomotic leakage rate.

CONCLUSION

RAS demonstrates favorable outcomes for rectal cancer patients, contributing to global prevention and control efforts, health promotion, and addressing non-communicable disease risk factors. Further research and public awareness are needed to optimize RAS utilization in this context.

A systematic review and meta-analysis of short-term outcomes comparing the efficacy of robotic versus laparoscopic colorectal surgery in obese patients

This meta-analysis was conducted to evaluate and contrast the effectiveness of robotic-assisted and laparoscopic colorectal surgery in the treatment of obese patients. In February 2024, we carried out an exhaustive search of key global databases including PubMed, Embase, and Google Scholar, limiting our focus to studies published in English and Chinese. We excluded reviews, protocols lacking published results, articles derived solely from conference abstracts, and studies not relevant to our research objectives. To analyze categorical variables, we utilized the Cochran-Mantel-Haenszel method along with random-effects models, calculating inverse variances and presenting the outcomes as odds ratios (ORs) along with their 95% confidence intervals (CIs). Statistical significance was determined when p values were less than 0.05. In our final meta-analysis, we included eight cohort studies, encompassing a total of 5,004 patients. When comparing the robotic surgery group to the laparoscopic group, the findings revealed that the robotic group experienced a longer operative time (weighted mean difference (WMD) = 37.53 min, 95% (CI) 15.58-59.47; p = 0.0008), a shorter hospital stay (WMD = -0.68 days, 95% CI -1.25 to -0.10; p = 0.02), and reduced blood loss (WMD = -49.23 mL, 95% CI -64.31 to -34.14; p < 0.00001). No significant differences were observed between the two groups regarding overall complications, conversion rates, surgical site infections, readmission rates, lymph node yield, anastomotic leakage, and intestinal obstruction. The results of our study indicate that robot-assisted colorectal surgery offers benefits for obese patients by shortening the length of hospital stay and minimizing blood loss when compared to laparoscopic surgery. Nonetheless, it is associated with longer operation times and shows no significant difference in terms of overall complications, conversion rates, rehospitalization rates, and other similar metrics.

Effect of prolonged operative time on short-term outcomes of open vs minimally invasive proctectomy

BACKGROUND

Minimally invasive proctectomy (MIP) may offer advantages over open proctectomy (OP). Increased operative times (OTs) are linked to inferior outcomes for various operations; however, the interplay between OT and approach for proctectomy is not well-established. This study aimed to evaluate associations of increasing OT on 30-day morbidity in OP and MIP cohorts.

METHODS

The American College of Surgeons National Quality Improvement Program Targeted Proctectomy Dataset was used to identify patients undergoing proctectomy. Cases were stratified by open or minimally invasive surgical approach and following propensity score matching between the groups, and OT quartiles were established for each group. Perioperative outcomes were compared among quartiles, and multivariate regression was used to identify factors associated with prolonged OT.

RESULTS

The median OT was longer for MIP (271 vs 232 min; P < .01). Although increased OT was associated with higher overall morbidity for both open and minimally invasive approaches, this effect was more pronounced in OP than in MIP (63.2% vs 38.4%, respectively; P < .001). Factors associated with prolonged OT included the procedure performed, male sex, higher body mass index scores, diverting ileostomy, and, in malignant disease, mid or lower and T4 tumors (all P < .05).

CONCLUSION

Herein, prolonged OT was associated with worse short-term outcomes for both OP and MIP cases; however, its detrimental effect was more pronounced for open surgery than for minimally invasive surgery. Our data suggested that MIP may offer short-term advantages for demanding cases requiring longer OTs.

Economic analysis of open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: A systematic review

OBJECTIVES

Minimally invasive total mesorectal excision is increasingly being used as an alternative to open surgery in the treatment of patients with rectal cancer. This systematic review aimed to compare the total, operative and hospitalization costs of open, laparoscopic, robot-assisted and transanal total mesorectal excision.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) (S1 File) A literature review was conducted (end-of-search date: January 1, 2023) and quality assessment performed using the Consensus Health Economic Criteria.

RESULTS

12 studies were included, reporting on 2542 patients (226 open, 1192 laparoscopic, 998 robot-assisted and 126 transanal total mesorectal excision). Total costs of minimally invasive total mesorectal excision were higher compared to the open technique in the majority of included studies. For robot-assisted total mesorectal excision, higher operative costs and lower hospitalization costs were reported compared to the open and laparoscopic technique. A meta-analysis could not be performed due to low study quality and a high level of heterogeneity. Heterogeneity was caused by differences in the learning curve and statistical methods used.

CONCLUSION

Literature regarding costs of total mesorectal excision techniques is limited in quality and number. Available evidence suggests minimally invasive techniques may be more expensive compared to open total mesorectal excision. High-quality economical evaluations, accounting for the learning curve, are needed to properly assess costs of the different techniques.

Short-term outcomes in robotic vs laparoscopic ileal pouch-anal anastomosis surgery: a propensity score match study

PURPOSE

Laparoscopic ileal pouch-anal anastomosis (IPAA) surgery offers improved short-term outcomes over open surgery but can be technically challenging. Robotic surgery has been increasingly used for IPAA surgery, but there is limited evidence supporting its use. This study aims to compare the short-term outcomes of laparoscopic and robotic IPAA procedures.

METHODS

All consecutive patients receiving laparoscopic and robotic IPAA surgery at 3 centres, from 3 countries, between 2008 and 2019 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for gender, previous abdominal surgery, ASA grade (I, II vs III, IV) and procedure performed (proctocolectomy vs completion proctectomy). Their short-term outcomes were examined.

RESULTS

A total of 89 patients were identified (73 laparoscopic, 16 robotic). The 16 patients that received robotic surgery were matched with 15 laparoscopic patients. Baseline characteristics were similar between the two groups. There were no statistically significant differences in any of the investigated short-term outcomes. Length of stay trend was higher for laparoscopic surgery (9 vs 7 days, p = 0.072) CONCLUSION: Robotic IPAA surgery is safe and feasible and offers similar short-term outcomes to laparoscopic surgery. Length of stay may be lower for robotic IPAA surgery, but further larger scale studies are required in order to demonstrate this.

Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis

BACKGROUND

Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection.

METHOD

Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates.

RESULTS

Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias.

CONCLUSION

Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.

Clinical Safety and Effectiveness of Robotic-Assisted Surgery in Patients with Rectal Cancer: Real-World Experience over 8 Years of Multiple Institutions with High-Volume Robotic-Assisted Surgery

The perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) are unclear. This retrospective observational study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions in Taiwan. Of the 605 enrolled patients, 301 (49.75%), 176 (29.09%), and 116 (19.17%) had lower, middle, and upper rectal cancers, respectively. Low anterior resection (377, 62.31%) was the most frequent surgical procedure. Intraoperative blood transfusion was performed in 10 patients (2%). The surgery was converted to an open one for one patient (0.2%), and ten (1.7%) patients underwent reoperation. The overall complication rate was 14.5%, including 3% from anastomosis leakage. No deaths occurred during surgery and within 30 days postoperatively. The positive rates of distal resection margin and circumferential resection margin were observed in 21 (3.5%) and 30 (5.0%) patients, respectively. The 5-year overall and disease-free survival rates for patients with stage I-III rectal cancer were 91.1% and 86.3%, respectively. This is the first multi-institutional study in Taiwan with 605 patients from three high-volume hospitals. The overall surgical and oncological outcomes were equivalent or superior to those estimated in other studies. Hence, RRS is an effective and safe technique for rectal resection in high-volume hospitals.

Robotic Surgery in Rectal Cancer: Potential, Challenges, and Opportunities

The current standard treatment for locally advanced rectal cancer is based on a multimodal comprehensive treatment combined with preoperative neoadjuvant chemoradiation and complete surgical resection of the entire mesorectal cancer. For ultra-low cases and cases with lateral lymph node metastasis, due to limitations in laparoscopic technology, the difficulties of operation and incidence of intraoperative complications are always difficult to overcome. Robotic surgery for the treatment of rectal cancer is an emerging technique that can overcome some of the technical drawbacks posed by conventional laparoscopic approaches, improving the scope and effect of radical operations. However, evidence from the literature regarding its oncological safety and clinical outcomes is still lacking. This brief review summarized the current status of robotic technology in rectal cancer therapy from the perspective of several mainstream surgical methods, including robotic total mesorectal excision (TME), robotic transanal TME, robotic lateral lymph node dissection, and artificial intelligence, focusing on the developmental direction of robotic approach in the field of minimally invasive surgery for rectal cancer in the future.

The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms "laparoscopic" and "robotic". Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons' expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12-2.10, p = 0.007). The analysis of the procedures performed by "expert surgeons" showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03-2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20-5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

Robotic-Assisted vs. Standard Laparoscopic Surgery for Rectal Cancer Resection: A Systematic Review and Meta-Analysis of 19,731 Patients

Simple Summary

Surgery remains a mainstay of combined modality treatment at patients with rectal cancer; however, there is a growing interest in using laparoscopic techniques (LG); including robotic-assisted techniques (RG). Therefore, we have prepared a meta-analysis of the literature regarding the safety and efficacy of robotic versus laparoscopic approaches in patients undergoing curative surgery for rectal cancer. The results indicate a number of advantages of RG in terms of both safety and efficacy. Operative time in the RG group was shorter and associated with a statistically significantly lower conversion of the procedure to open surgery. RG technique provided a shorter duration of hospital stay and lowered urinary risk retention. No differences were found between these techniques regarding TNM stage; N stage or lymph nodes harvested. Survival to hospital discharge or 30-day overall survival rate was 99.6% in RG vs. 98.8% for LG.

Abstract

Robotic-assisted surgery is expected to have advantages over standard laparoscopic approach in patients undergoing curative surgery for rectal cancer. PubMed, Cochrane Library, Web of Science, Scopus and Google Scholar were searched from database inception to 10 November 2021, for both RCTs and observational studies comparing robotic-assisted versus standard laparoscopic surgery for rectal cancer resection. Where possible, data were pooled using random effects meta-analysis. Forty-Two were considered eligible for the meta-analysis. Survival to hospital discharge or 30-day overall survival rate was 99.6% for RG and 98.8% for LG (OR = 2.10; 95% CI: 1.00 to 4.43; p = 0.05). Time to first flatus in the RG group was 2.5 ± 1.4 days and was statistically significantly shorter than in LG group (2.9 ± 2.0 days; MD = −0.34; 95%CI: −0.65 to 0.03; p = 0.03). In the case of time to a liquid diet, solid diet and bowel movement, the analysis showed no statistically significant differences (p > 0.05). Length of hospital stay in the RG vs. LG group varied and amounted to 8.0 ± 5.3 vs. 9.5 ± 10.0 days (MD = −2.01; 95%CI: −2.90 to −1.11; p < 0.001). Overall, 30-days complications in the RG and LG groups were 27.2% and 19.0% (OR = 1.11; 95%CI: 0.80 to 1.55; p = 0.53), respectively. In summary, robotic-assisted techniques provide several advantages over laparoscopic techniques in reducing operative time, significantly lowering conversion of the procedure to open surgery, shortening the duration of hospital stay, lowering the risk of urinary retention, improving survival to hospital discharge or 30-day overall survival rate.

Robotic and robotic-assisted vs laparoscopic rectal cancer surgery: A meta-analysis of short-term and long-term results

The usage of robotic surgery in rectal cancer (RC) is increasing, but there is an ongoing debate as to whether it provides any benefit. This study conducted a meta-analysis of rectal cancer surgery for short-term and long-term outcome by Robotic and robotic-assisted surgery (RS) vs laparoscopic surgery (LS).Pubmed, Embase, Ovid, CNKI, Cochrane Library and Web of Science databases were searched. Studies clearly documenting a comparison of short-term and long-term effect between RS and LS for RC were selected. Lymph node harvested, operation time, hospital stay, circumferential resection margins（CRM), complications, 3-year disease-free survival (DFS) and 5-year DFS parameters were evaluated. All data were performed by Review Manager 5.3 software. Nine studies were collected that included 1436 cases in total, 716 (49.86%) in the RS group, 720(50.14%) in the LS group. Compared with LS, RS was associated with longer operation time (MD 35.19, 95%CI [7.57, 62.81]; P = 0.01), but similar hospital stay (MD -0.43, 95%CI [-0.87,0.01]; P = 0.05).Lymph node harvested, CRM, complications, 3-year DFS, 5-year DFS had no significance difference between RS and LS groups（MD -0.67，95%CI[-1.53，0.19]；P = 0.13；MD 0.86，95%CI[0.54,1.37]；P = 0.52；MD 0.97，95%CI [0.73,1.29]；P = 0.86；MD 0.94，95%CI[0.60,1.48]；P = 0.79；MD 0.88，95%CI[0.52,1.47]；P = 0.61 respectively）.RS is feasible and safe for RC. It has an advantage in short -term outcome and a similar effect in long-term outcome compared with LS.

Options for Low Rectal Cancer: Robotic Total Mesorectal Excision

Low rectal cancers (LRCs) may offer a difficult technical challenge even to experienced colorectal surgeons. Although laparoscopic surgery offers a superior exposure of the pelvis when compared with open approach, its role in rectal cancer surgery has been controversial. Robotic platforms are well suited for difficult pelvic surgery due to its three-dimensional visualization, degree of articulation of instruments, precise movements, and better ergonomics. The robot may be suitable especially in the anatomically narrow pelvis such as in male and obese patients. Meticulous dissection in critical steps, such as splenic flexure takedown, nerve-sparing mesorectal excision, and distal margin clearance, are potential technical advantages. In addition, robotic rectal resections are associated with lower conversion rates to open surgery, less blood loss, and shorter learning curve with similar short-term quality of life outcomes, similar rates of postoperative complications, and equivalent short-term surrogate outcomes compared with conventional laparoscopy. Robotic surgery approach, if used correctly, can enhance the skills and the capabilities of the well-trained surgeon during minimally invasive procedures for LRC.

Robotic Surgery in Crohn's Disease

Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.

Oncological outcomes of robotic-assisted total mesorectal excision after neoadjuvant concurrent chemoradiotherapy in patients with rectal cancer

AIMS

This study analyzed the oncological outcomes of robotic-assisted total mesorectal excision (TME) in patients with rectal cancer after neoadjuvant concurrent chemoradiotherapy (CCRT).

METHODS

We enrolled 109 consecutive patients with stage II-III rectal cancer who underwent robotic-assisted TME after neoadjuvant CCRT at one hospital between July 2013 and June 2018.

RESULTS

All 109 patients underwent preoperative CCRT. Of them, 37 (33.9%) achieved a pathologic complete response, and 29 (26.6%) experienced relapse, with local recurrence in 9 (8.3%) and distant metastasis in 20 (18.3%). R0 resection was performed in 104 (95.7%) patients; however, 7 (6.7%) of them developed local recurrence and 17 (16.3%) developed distant metastasis. Over a median follow-up of 42 months, the 3-year disease-free survival and overall survival rates were 73.4% and 87.2%, respectively.

CONCLUSIONS

Robotic-assisted TME after neoadjuvant CCRT is safe and effective for treating patients with stage II-III rectal cancer in one institution with acceptable short-term oncological outcomes. It may be a therapeutic alternative to salvage surgery for T4 tumors invading adjacent organs, such as the bladder, prostate, and uterus.

Feasibility of robot-assisted surgery in elderly patients with rectal cancer

BACKGROUND

Although surgical resection is the main treatment for rectal cancer, the optimal surgical protocol for elderly patients with rectal cancer remains controversial. This study evaluated the feasibility of robot-assisted surgery in elderly patients with rectal cancer.

PATIENTS AND METHODS

This retrospective study enrolled 156 patients aged 28-93 years diagnosed with Stage I-III rectal cancer, who underwent robot-assisted surgery between May 2013 and December 2018 at a single institution.

RESULTS

In total, 156 patients with rectal cancer, including 126 non-elderly (aged < 70 years) and 30 elderly (aged ≥70 years) patients, who underwent robot-assisted surgery were recruited. Between the patient groups, the post-operative length of hospital stay did not differ statistically significantly (P = 0.084). The incidence of overall post-operative complications was statistically significantly lower in the elderly group (P = 0.002). The disease-free and overall survival did not differ statistically significantly between the two groups (P = 0.719 and 0.390, respectively).

CONCLUSIONS

Robot-assisted surgery for rectal cancer was well tolerated by elderly patients, with similar results to the non-elderly patients. Oncological outcomes and survival did not depend on patient age, suggesting that robot-assisted surgery is a feasible surgical modality for treating operable rectal cancer and leads to age-independent post-operative outcomes in elderly patients.

Difference in surgical outcomes of rectal cancer by study design: meta-analyses of randomized clinical trials, case-matched studies, and cohort studies

Background

RCTs are considered the standard in surgical research, whereas case-matched studies and propensity score matching studies are conducted as an alternative option. Both study designs have been used to investigate the potential superiority of robotic surgery over laparoscopic surgery for rectal cancer. However, no conclusion has been reached regarding whether there are differences in findings according to study design. This study aimed to examine similarities and differences in findings relating to robotic surgery for rectal cancer by study design.

Methods

A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane CENTRAL to identify RCTs, case-matched studies, and cohort studies that compared robotic versus laparoscopic surgery for rectal cancer. Primary outcomes were incidence of postoperative overall complications, incidence of anastomotic leakage, and postoperative mortality. Meta-analyses were performed for each study design using a random-effects model.

Results

Fifty-nine articles were identified and reviewed. No differences were observed in incidence of anastomotic leakage, mortality, rate of positive circumferential resection margins, conversion rate, and duration of operation by study design. With respect to the incidence of postoperative overall complications and duration of hospital stay, the superiority of robotic surgery was most evident in cohort studies (risk ratio (RR) 0.83, 95 per cent c.i. 0.74 to 0.92, P < 0.001; mean difference (MD) –1.11 (95 per cent c.i. –1.86 to –0.36) days, P = 0.004; respectively), and least evident in RCTs (RR 1.12, 0.91 to 1.38, P = 0.27; MD –0.28 (–1.44 to 0.88) days, P = 0.64; respectively).

Conclusion

Results of case-matched studies were often similar to those of RCTs in terms of outcomes of robotic surgery for rectal cancer. However, case-matched studies occasionally overestimated the effects of interventions compared with RCTs.

Clinical and oncological outcomes of the low ligation of the inferior mesenteric artery with robotic surgery in patients with rectal cancer following neoadjuvant chemoradiotherapy

Background/aim

The aim of this study is to compare clinical and oncologic outcomes of the high and low ligation techniques of the inferior mesenteric artery (IMA) in rectal cancer patients treated with robotic surgery after neoadjuvant chemoradiotherapy (nCRT).

Materials and methods

In this retrospective study, 77 patients with T3/T4-node negative rectal cancer with tumor penetration through the muscle wall (Stage 2) or node positive disease without distant metastases (Stage 3) who were treated electively with robotic surgical resection following nCRT at a single institution between January 2014 and January 2018 were analyzed. Patients were divided into 2 groups (38 patients were included in the low ligation group and 39 patients in the high ligation group).

Results

There was no statistical difference between the high ligation group and low ligation group in univariate analysis for 2-year overall survival and disease-free survival (OR = 1.146; 95% CI = 0.274 to 4.797; P = 0.950, and OR = 1.141; 95% CI = 0.564 to 2.308; P = 0.713, respectively). There was no significant difference between the 2 groups in the mean number of harvested lymph nodes and mean number of metastatic lymph nodes (P = 0.980 and P = 0.124, respectively). Anastomosis stricture was observed significantly less frequently in the low ligation group versus the high ligation group (2.6% and 28.2%, respectively) (P = 0.002). Also, the difference for the median length of hospital stay for the high and low ligation groups was statistically significant in favor of the low ligation group (P = 0.011).

Conclusion

In robotic rectal surgery, the low ligation technique of the IMA can reduce the rate of anastomosis stricture and provide similar oncological results as the high ligation technique.

Impact of previous abdominal surgery on robotic-assisted rectal surgery in patients with locally advanced rectal adenocarcinoma: a propensity score matching study

BACKGROUND

The application of minimally invasive surgery in patients with colorectal cancer (CRC) and a history of previous abdominal surgery (PAS) remains controversial. This retrospective study with propensity score matching (PSM) investigated the impact of PAS on robotic-assisted rectal surgery outcomes in patients with locally advanced rectal adenocarcinoma undergoing preoperative concurrent chemoradiotherapy (CCRT).

METHODS

In total, 203 patients with locally advanced rectal adenocarcinoma who underwent preoperative CCRT and robotic-assisted rectal surgery between May 2013 and December 2019 were enrolled. Patients were categorized into PAS and non-PAS groups based on the PAS history. The PSM caliper matching method with 1-to-3 matches was used to match PAS patients with non-PAS.

RESULTS

Of the 203 enrolled patients, 35 were PAS patients and 168 were non-PAS patients. After PSM, 32 PAS patients and 96 non-PAS patients were included for analysis. No significant between-group differences were noted in the perioperative outcomes, including median console time (165 min (PAS) vs. 175 min (non-PAS), P = 0.4542) and median operation time (275 min (PAS) vs. 290 min (non-PAS), P = 0.5943) after PSM. Postoperative recovery and overall complication rates were also similar (all P > 0.05). Moreover, the between-group differences in pathological or short-term oncological outcomes were also nonsignificant (all P > 0.05). No 30-day postoperative deaths were observed in either group.

CONCLUSION

The current results indicate that robotic-assisted surgery is safe and feasible for PAS patients with locally advanced rectal adenocarcinoma undergoing preoperative CCRT. However, future prospective randomized clinical trials are required to verify these findings.

Effective implementation and adaptation of structured robotic colorectal programme in a busy tertiary unit

BACKGROUND

Safety and feasibility of robotic colorectal surgery has been reported as increasing over the last decade. However safe implementation and adaptation of such a programme with comparable morbidities and acceptable oncological outcomes remains a challenge in a busy tertiary unit. We present our experience of implementation and adaptation of a structured robotic colorectal programme in a high-volume center in the United Kingdom.

METHODS

Two colorectal surgeons underwent a structured robotic colorectal training programme consisting of time on simulation console, dry and wet laboratory courses, case observation, and initial mentoring. Data were collected on consecutive robotic colorectal cancer resections over a period of 12 months and compared with colorectal cancer resections data of the same surgeons' record prior to the adaptation of the new technique. Patient demographics including age, gender, American Society of Anesthesiologist score (ASA), Clavien-Dindo grading, previous abdominal surgeries, and BMI were included. Short-term outcomes including conversion to open, length of stay, return to theatre, 30- and 90-days mortality, blood loss, and post-operative analgesia were recorded. Tumour site, TNM staging, diverting stoma, neo-adjuvant therapy, total mesorectal excision (TME) grading and positive resection margins (R1) were compared. p values less than or equal to 0.05 were considered statistically significant.

RESULTS

Ninety colorectal cancer resections were performed with curative intent from June 2018 to June 2020. Thirty robotic colorectal cancer resections (RCcR) were performed after adaption of programme and were compared with 60 non-robotic colorectal cancer resections (N-RCcR) prior to implementation of technique. There was no conversion in the RCcR group; however, in N-RCcR group, five had open resection from start and the rest had laparoscopic surgery. In laparoscopic group, there were six (10.9%) conversions to open (two adhesions, three multi-visceral involvements, one intra-operative bleed). Male-to-female ratio was 20:09 in RCcR group and 33:20 in N-RCcR groups. No significant differences in gender (p = 0.5), median age (p = 0.47), BMI (p = 0.64) and ASA scores (p = 0.72) were present in either groups. Patient characteristics between the two groups were comparable aside from an increased proportion of rectal and sigmoid cancers in RCcR group. Mean operating time, and returns to theaters were comparable in both groups. Complications were fewer in RCcR group as compared to N-RCcR (16.6% vs 25%). RCcR group patients have reduced length of stay (5 days vs 7 days) but this is not statistically significant. Estimated blood loss and conversion to open surgery was significantly lesser in the robotic group (p < 0.01). The oncological outcomes from surgery including TNM, resection margin status, lymph node yield and circumferential resection margin (for rectal cancers) were all comparable. There was no 30-day mortality in either group.

CONCLUSION

Implementation and integration of robotic colorectal surgery is safe and effective in a busy tertiary center through a structured training programme with comparable short-term survival and oncological outcomes during learning curve.

Robotic vs laparoscopic total mesorectal excision for rectal cancers: has a paradigm change occurred? A systematic review by updated meta-analysis

AIM

The debate about the oncological adequacy, safety and efficiency of robotic vs laparoscopic total mesorectal excision for rectal cancers continues. Therefore, an updated, traditional and cumulative meta-analysis was performed with the aim of assessing the new evidence on this topic.

METHOD

A systematic search of the literature for data pertaining to the last 25 years was performed. Fixed- and random-effects models were used to cumulatively assess the accumulation of evidence over time.

RESULTS

Patients with a significantly higher body mass index (BMI), tumours located approximately 1 cm further distally and more patients undergoing neoadjuvant therapy were included in the robotic total mesorectal excision (RTME) cohort compared with those in the laparoscopic total mesorectal excision (LTME) cohort [RTME, mean difference (MD) = 0.22 (0.07, 0.36), P = 0.005; LTME, MD = -0.97 (-1.57, 0.36), P < 0.002; OR = 1.47 (1.11, 1.93), P = 0.006]. Significantly lower conversion rates to open surgery were observed in the RTME cohort than in the LTME cohort [OR = 0.33 (0.24, 0.46), P < 0.001]. Operative time in the LTME cohort was significantly reduced (by 50 min) compared with the RTME cohort. Subgroup analysis of the three randomized controlled trials (RCTs) challenged all the significant results of the main analysis and demonstrated nonsignificant differences between the RTME cohort and LTME cohort.

CONCLUSION

Although the RTME cohort included patients with a significantly higher BMI, more distal tumours and more patients undergoing neoadjuvant therapy, this cohort demonstrated lower conversion rates to open surgery when compared with the LTME cohort. However, subgroup analysis of the RCTs demonstrated nonsignificant differences between the two procedures.

Robotic Total Mesorectal Excision for Rectal Cancer: Current Evidences and Future Perspectives

Despite the technical limitations of minimally invasive surgery, laparoscopic total mesorectal excision (LTME) for rectal cancer has short-term advantages over open surgery, but the pathological outcomes reported in randomized clinical trials are still in controversy. Minimally invasive robotic total mesorectal excision (RTME) has recently been gaining popularity as robotic surgical systems potentially provide greater benefits than LTME. Compared to LTME, RTME is associated with lower conversion rates and similar or better genitourinary functions, but its long-term oncological outcomes have not been established. Although the operating time of RTME is longer than that of LTME, RTME has a shorter learning curve, is more convenient for surgeons, and is better for sphincter-preserving operations than LTME. The robotic surgical system is a good technical tool for minimally invasive surgery for rectal cancer, especially in male patients with narrow deep pelvises. Robotic systems and robotic surgical techniques are still improving, and the contribution of RTME to the treatment of rectal cancer will continue to increase in the future.

Oncological Outcomes of Robotic-Assisted Surgery With High Dissection and Selective Ligation Technique for Sigmoid Colon and Rectal Cancer

Background: Curative resection of sigmoid colon and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the complication rate. We present preliminary experiences of operative and oncologic outcomes of patients with rectal or sigmoid colon cancer who underwent robotic surgery employing the high dissection and selective ligation technique. Methods: Over May 2013 to April 2017, 113 stage I-III rectal or sigmoid colon cancer patients underwent robotic surgery with the single-docking technique at one institution. We performed D3 lymph node dissection and low-tie ligation of the IMA (i.e., high dissection and selective ligation technique). Clinicopathological features, perioperative parameters, and postoperative outcomes were retrospectively analyzed. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Results: Sphincter preservation rate was 96.3% in rectal cancer patients. Median number of harvested lymph nodes was 12. Apical nodes were pathologically harvested in 84 (82.4%) patients. R0 resection was performed in 108 (95.6%) patients. Overall complication rate was 17.7%; but most complications were mild and the patients recovered uneventfully. Estimated 5-year OS was 86.1% and 3-year DFS was 79.6% after median follow-up periods of 49.1 months (range, 5.3-85.3). Conclusions: High dissection of the IMA and selective ligation of the major feeding vessel to the sigmoid colon or rectum can be safely performed using da Vinci Surgical System,yielding favorable clinical, and oncologic outcomes in rectal or sigmoid colon cancer treatment.

Time interval between the completion of radiotherapy and robotic-assisted surgery among patients with stage I-III rectal cancer undergoing preoperative chemoradiotherapy

BACKGROUND

This aim of this study was to evaluate the effects of time interval between the completion of radiotherapy and robotic-assisted surgery on the outcomes among patients with rectal cancer undergoing preoperative concurrent chemoradiotherapy (CCRT).

METHODS

In total, 116 patients with stage I-III rectal cancer who underwent preoperative CCRT and robotic-assisted surgery between September 2013 and February 2019 were enrolled. Patients were categorized into two groups based on the time interval: group A (10-12 weeks) and group B (≥ 12 weeks).

RESULTS

Among the 116 enrolled patients, 98 (84.5%) had middle and lower rectal cancers. Two (1.7%) patients underwent abdominoperineal resection with a sphincter preservation rate of 98.3%. Thirty-seven (31.9%) patients had a pathologic complete response (pCR). The circumferential resection margin and distal resection margin were positive in 2 (1.7%) and 1 (0.9%) patients, respectively. Therefore, the R0 resection rate was 97.4%. A total of 24 (22.4%) patients experienced postoperative relapse and 12 (10.3%) patients died; these were slightly more common in group B than in group A (28.8% vs 15.8% and 15.3% vs 5.3%, respectively; both P > 0.05); however, this difference was nonsignificant. Three-year disease-free survival (DFS) and overall survival (OS) were 75% and 89%, respectively, among all patients. Non-significant trend of favorable 3-year DFS, 3-year OS, 3-year locoregional control rate and 3-year distant metastasis control rate were observed in group A compared with group B (all P > 0.05).

CONCLUSION

Robotic-assisted surgery after a longer interval is safe and feasible for patients with rectal cancer undergoing preoperative CCRT. The present study's results suggested that the time interval of 10-12 weeks can be considered because comparable clinical and perioperative outcomes and preferable oncological outcomes were observed for interval of this length. However, future prospective randomized clinical trials are required to verify the present finding.

Comparison of clinical efficacy between robotic-laparoscopic excision and traditional laparoscopy for rectal cancer: A protocol for systematic review and meta-analysis

BACKGROUNDS

Laparoscopic surgery, robot-assisted surgery and open surgery are the most commonly consumed surgical techniques in daily living. Considering that in recent years, the situation of choosing laparoscopic surgery and robot-assisted surgery to treat rectal cancer in China is prosperous. Meanwhile, researches lacked in the comparison part between the 2, so we will systematically compare the clinical efficacy of robot-assisted resection and traditional laparoscopic resection for rectal cancer.

METHODS AND ANALYSIS

We will search Clinical research literature published before January 2020 in PubMed, Embase, the Cochrane library, Science Network, Wan Fang database, Chinese national knowledge infrastructure, and Chinese biomedicine that evaluate the correlation of rectal cancer with Leonardo's robot and traditional laparoscopy, from inception to July 2019. Weighted mean difference and odds ratio were used to compare the efficacy of robot-assisted resection versus conventional laparoscopic resection for rectal cancer, and the main indicators are operation time, complication rate, conversion rate, blood loss, and length of stay.

RESULTS AND CONCLUSION

This study will systematically evaluate the clinical efficacy of robot-assisted resection and traditional laparoscopic resection for rectal cancer, thus providing evidence to the clinical application. The results will be published in a peer-reviewed journal.

ETHICS AND DISSEMINATION

No ethical approval and participant consent are required, since this study data is based on published literature. The results of the study will be submitted to a peer-reviewed journal.PROSPERO registration number: CRD42020172161.

Outcomes of Minimally Invasive Versus Open Proctectomy for Rectal Cancer: A Propensity-Matched Analysis of Bi-National Colorectal Cancer Audit Data

BACKGROUND

Minimally invasive surgery is commonly used in the treatment of rectal cancer, despite the lack of evidence to support oncological equivalence or improved recovery compared with open surgery.

OBJECTIVE

This study aims to analyze prospectively collected data from a large Australasian colorectal cancer database.

DESIGN

This is a retrospective cohort study using propensity score matching.

SETTING

This study was conducted using data supplied by the Bi-National Colorectal Cancer Audit.

PATIENTS

A total of 3451 patients who underwent open (n = 1980), laparoscopic (n = 1269), robotic (n = 117), and transanal total mesorectal excision (n = 85) for rectal cancer were included in this study.

MAIN OUTCOME MEASURE

The primary outcome was positive margin rates (circumferential resection margin and/or distal resection margin) in patients treated with curative intent.

RESULTS

Propensity score matching yielded 1132 patients in each of the open and minimally invasive surgery groups. Margin positivity rates and lymph node yields did not differ between groups. The open group had a significantly lower total complication rate (27.6% vs 35.8%, p < 0.0001), including a lower rate of postoperative small-bowel obstruction (1.2% vs 2.5%, p = 0.03). The minimally invasive surgery group had significantly lower wound infection rate (2.9% vs 5.0%, p = 0.02) and a shorter length of hospital stay (8 vs 9 days, p < 0.0001). There was no difference in 30-day mortality.

LIMITATIONS

Results are limited by the quality of registry data entries.

CONCLUSION

In this patient population, minimally invasive proctectomy demonstrated similar margin rates in comparison with open proctectomy, with a reduced length of stay but a higher overall complication rate. See Video Abstract at http://links.lww.com/DCR/B190. RESULTADOS DE LA PROCTECTOMÍA MÍNIMA INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PROPENSIÓN DE LOS DATOS BINACIONALES DE AUDITORÍA DEL CÁNCER COLORRECTAL: La cirugía mínima invasiva, frecuentemente se utiliza en el tratamiento del cáncer rectal, a pesar de la falta de evidencia que respalde la equivalencia oncológica o la mejor recuperación, en comparación con la cirugía abierta.El estudio tiene como objetivo analizar datos prospectivamente obtenidos, de una gran base de datos de cáncer colorrectal de Australia.Estudio de cohorte retrospectivo utilizando el emparejamiento de puntaje de propensión.Este estudio se realizó utilizando datos proporcionados por la Auditoría Binacional del Cáncer Colorrectal.Se incluyeron en este estudio un total de 3451 pacientes que se trataron de manera abierta (n = 1980), laparoscópica (n = 1269), robótica (n = 117) y taTME (n = 85) para cáncer rectal.Los resultados primarios fueron de tasas de margen positivas (margen de resección circunferencial y/o margen de resección distal) en pacientes con intención curativa.La coincidencia de puntaje de propensión arrojó 1132 pacientes en cada uno de los grupos de cirugía abierta y mínima invasiva. Las tasas de positividad del margen y los rendimientos de los ganglios linfáticos no difirieron entre los dos grupos. El grupo abierto tuvo una tasa de complicaciones totales significativamente menor (27.6% vs 35.8%, p <0.0001), incluida una tasa menor de obstrucción postoperatoria del intestino delgado (1.2% vs 2.5%, p = 0.03). El grupo de cirugía mínimamente invasiva tuvo una tasa de infección de la herida significativamente menor (2.9% frente a 5.0%, p = 0,02) y una estancia hospitalaria más corta (8 frente a 9 días, p <0.0001). No hubo diferencias en la mortalidad a los 30 días.Los resultados están limitados por la calidad de la entrada de datos de registro.En esta población de pacientes, la proctectomía mínima invasiva demostró tasas de margen similares en comparación con la proctectomía abierta, con una estadía reducida pero una tasa más alta de complicaciones en general. Consulte Video Resumen en http://links.lww.com/DCR/B190. (Traducción-Dr. Fidel Ruiz Healy).

Rate of conversion to an open procedure is reduced in patients undergoing robotic colorectal surgery: A single-institution experience

Background

Robotic-assisted surgery is becoming increasingly used in colorectal operations. It has many advantages over laparoscopic surgery including three-dimensional viewing, motion scaling, improved dexterity and ergonomics as well as increased precision. However, there are also disadvantages to robotic surgery such as lack of tactile feedback, cost as well as limitations on multi-quadrant surgeries. The purpose of this study was to compare the rate of conversion to an open surgery in patients undergoing robotic-assisted colorectal surgery and traditional laparoscopic surgery.

Methods

Patients undergoing minimally invasive colorectal surgery for neoplastic and dysplastic disease from 2009 to 2016 were identified and examined retrospectively. The statistical software SAS, manufactured by SAS Institute, Cary, North Carolina. Continuous variables were analysed using analysis of variance test. Chi-square test was used to analyse categorical variables. P <0.05 was considered statistically significant.

Results

Two hundred and thirty-five patients were identified that underwent minimally invasive colorectal surgery. One hundred and sixty-four underwent laparoscopic resection and 71 underwent robotic-assisted resection. There was no statistical difference in gender or race between the two groups (both P > 0.05). Patients that underwent robotic-assisted resection were slightly younger than patients that underwent laparoscopic resection (61.6 years vs. 65.6 years; P= 0.02). When examining conversion to an open procedure, patients that underwent robotic-assisted resection had a significantly lower chance of conversion than did the patients undergoing a laparoscopic approach (11.27% vs. 29.78%; P= 0.0018).

Conclusion

Conversion rates from a minimally invasive procedure to an open procedure appear to be lower with robotic-assisted surgery compared to laparoscopic surgery.

Safe surgery in the elderly: A review of outcomes following robotic proctectomy from the Nationwide Inpatient Sample in a cross-sectional study

Background

As our nation's population ages, operating on older and sicker patients occurs more frequently. Robotic operations have been thought to bridge the gap between a laparoscopic and an open approach, especially in more complex cases like proctectomy.

Methods

Our objective was to evaluate the use and outcomes of robotic proctectomy compared to open and laparoscopic approaches for rectal cancer in the elderly. A retrospective cross-sectional cohort study utilizing the Nationwide Inpatient Sample (NIS; 2006-2013) was performed. All cases were restricted to age 70 years old or greater.

Results

We identified 6740 admissions for rectal cancer including: 5879 open, 666 laparoscopic, and 195 robotic procedures. The median age was 77 years old. The incidence of a robotic proctectomy increased by 39%, while the open approach declined by 6% over the time period studied. Median (interquartile range) length of stay was shorter for robotic procedures at 4.3 (3-7) days, compared to laparoscopic 5.8 (4-8) and open at 6.7 (5-10) days (p < 0.01), while median total hospital charges were greater in the robotic group compared to laparoscopic and open cases ($64,743 vs. $55,813 vs. $50,355, respectively, p < 0.01). There was no significant difference in the risk of total complications between the different approaches following multivariate analysis.

Conclusion

Robotic proctectomy was associated with a shorter LOS, and this may act as a surrogate marker for an overall improvement in adverse events. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities.

Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

BACKGROUND

Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS).

METHODS

All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded.

RESULTS

Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I² = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I² = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I² = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I² = 94%; REM: MD - 0.77; 95% CI 1.12, - 0.41; day), time to oral diet (ρ < 0.001, I² = 60%; REM: MD - 0.43; 95% CI - 0.64, - 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I² = 88%; REM: MD - 18.05; 95% CI - 32.24, - 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I² = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min).

CONCLUSIONS

This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.

Structured cost analysis of robotic TME resection for rectal cancer: a comparison between the da Vinci Si and Xi in a single surgeon's experience

BACKGROUND

Robotic-assisted surgery by the da Vinci Si appears to benefit rectal cancer surgery in selected patients, but still has some limitations, one of which is its high costs. Preliminary studies have indicated that the use of the new da Vinci Xi provides some added advantages, but their impact on cost is unknown. The aim of the present study is to compare surgical outcomes and costs of rectal cancer resection by the two platforms, in a single surgeon's experience.

METHODS

From April 2010 to April 2017, 90 robotic rectal resections were performed, with either the da Vinci Si (Si-RobTME) or the da Vinci Xi (Xi-RobTME). Based on CUSUM analysis, two comparable groups of 40 consecutive Si-RobTME and 40 consecutive Xi-RobTME were obtained from the prospectively collected database and used for the present retrospective comparative study. Data costs were analysed based on the level of experience on the proficiency-gain curve (p-g curve) by the surgeon with each platform.

RESULTS

In both groups, two homogeneous phases of the p-g curve were identified: Si1 and Xi1: cases 1-19, Si2 and Xi2: cases 20-40. A significantly higher number of full RAS operations were achieved in the Xi-RobTME group (p < 0.001). A statistically significant reduction in operating time (OT) during Si2 and Xi2 phase was observed (p < 0.001), accompanied by reduced overall variable costs (OVC), personnel costs (PC) and consumable costs (CC) (p < 0.001). All costs were lower in the Xi2 phase compared to Si2 phase: OT 265 versus 290 min (p = 0.052); OVC 7983 versus 10231.9 (p = 0.009); PC 1151.6 versus 1260.2 (p = 0.052), CC 3464.4 versus 3869.7 (p < 0.001).

CONCLUSIONS

Our experience confirms a significant reduction of costs with increasing surgeon's experience with both platforms. However, the economic gain was higher with the Xi with shorter OT, reduced PC and CC, in addition to a significantly larger number of cases performed by the fully robotic approach.

Short-Term Outcomes of Robotic versus Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Cohort Study

The aim of this study was to evaluate and compare the intestinal function recovery time and other short-term outcomes between robotic-assisted total mesorectal excision (R-TME) and laparoscopic total mesorectal excision (L-TME) for rectal cancer. This is a retrospective study using a prospectively collected database. Patients’ records were obtained from Gansu Provincial Hospital between July 2015 and October 2017. Eighty patients underwent R-TME, and 116 with the same histopathological stage of the tumor underwent an L-TME. Both operations were performed by the same surgeon, comparing intra- and postoperative outcomes intergroups. The time to the first passage of flatus ( P < 0.001), the time to the first postoperative oral fluid intake ( P < 0.001), and the length of hospital stay ( P < 0.01) of the R-TME group were about three days faster than those in the L-TME group. The rate of conversion to open laparotomy ( P = 0.038) and postoperative urinary retention ( P = 0.016) were significantly lower in the R-TME group than in the L-TME group. Intraoperative blood loss of the R-TME group was more than that of the L-TME group ( P < 0.01).The operation time, number of lymph nodes harvested, and rate of positive circumferential resection margin were similar intergroup. The total cost of the R-TME group was higher than that of the L-TME group, but with a lack of statistical significance (85,623.91 ± 13,310.50 vs 67,356.79 ± 17,107.68 CNY, P = 0.084). The R-TME is safe and effective and has better postoperative short-term outcomes and faster intestinal function recovery time, contrasting with the L-TME. The large, multicenter, prospective studies were needed to validate the advantages of robotic surgery system used in rectal cancer.

Robotic versus laparoscopic sphincter-preserving total mesorectal excision: A propensity case-matched analysis

BACKGROUND

Robotic total mesorectal excision (R-TME) is expected to have advantages over laparoscopic total mesorectal excision (L-TME). The aim is to compare the short-term outcomes between initial cases of L-TME and RTME.

MATERIALS AND METHODS

Among a total of 168 patients assigned to receive either R-TME (n = 84) or L-TME (n = 84), short term outcomes were compared between the groups by 1:1 propensity score matching of eight variables.

RESULTS

The inter-sphincteric resection rate (42.9% vs. 25%; P = 0.006) and operative time (372.4 ± 102.8 vs. 301 ± 53.6, P = 0.000) were significantly greater in R-TME. The conversion rate, blood loss, and length of hospital stay were similar. The anastomotic leak rate and major surgical complications rates were significantly higher in L-TME (9.5% vs. 1.2%; P = 0.016) and (13.1% vs. 4.8%; P = 0.034) respectively.

CONCLUSION

The oncologic quality and short-term outcomes in the two groups were comparable; however, anastomotic leak rates and major complications were significantly lower in R-TME. For experienced laparoscopic surgeons, robotic sphincter-saving TME is associated with lower morbidity when compared with laparoscopic approach.

Robotic vs laparoscopic rectal tumour surgery: a cohort study

AIM

The aim of this study was to compare robotic and laparoscopic rectal surgery in terms of perioperative data, short-term outcome and compliance to the Enhanced Recovery After Surgery (ERAS) protocol.

METHOD

In this cohort study, 224 patients scheduled for rectal resection for cancer or adenoma between January 2011 and January 2017 were evaluated. In the first time period (12 January 2011 to 23 April 2014), 47 (46%) of 102 patients had laparoscopic surgery. In the second time period (24 April 2014 to 30 January 2017), 72 (59%) of 122 patients had robotic surgery. Perioperative data and short-term outcome were collected from the ERAS database and patient charts. Data obtained from laparoscopic and robotic surgery in the two time periods studied were compared. Primary outcome was hospital length of stay (LOS) and secondary outcomes were compliance to the ERAS protocol, difference in postoperative complications and conversion to open surgery.

RESULTS

Compliance to the ERAS protocol was 81.1% in the robotic group and 83.4% in the laparoscopic group (P = 0.890). Robotic surgery was associated with shorter median LOS (3 days vs 7 days, P < 0.001), lower conversion rate (11.1% vs 34.0%, P = 0.002), lower rate of postoperative complications (25% vs 49%, P < 0.01) and longer duration of surgery (5.8 h vs 4.5 h, P < 0.001). The differences remained after multivariate analysis.

CONCLUSION

Robotic surgery was associated with shorter LOS, lower conversion rates and fewer postoperative complications compared with laparoscopic surgery. Robotic surgery may add benefits to the ERAS protocol.

Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis

BACKGROUND

The purpose of this meta-analysis is to evaluate the evidence available on the safety as well as effectiveness of robotic resection as compared to conventional laparoscopic surgery for rectal cancer.

MATERIAL AND METHODS

A comparison of laparoscopic and robotic surgical treatments for rectal cancer was collected. Eligible trials that analyzed probabilistic hazard ratios (HR) for endpoints of interest (including perioperative morbidity) and postoperative complications were included in our review.

RESULTS

A total of six studies were included based on the present inclusion criteria. The pooled data showed that R-TME appeared to have association with remarkable reduction in the postoperative morbidity rate as compared to L-TME. Moreover, R-TME was also linked to lower conversion, decreased lymph node number, and longer operation time compared with L-TME. However, there was no difference in hospital stay, positive range of circumferential resection and blood loss between the two study groups.

CONCLUSIONS

Robotic rectal cancer surgery provides favorable outcomes and is considered as a safe surgical technique in terms of postoperative oncological safety. Like laparoscopic TME surgery, robotic surgery may be a valid alternative and complementary approach with beneficial effects on minimally-invasive surgery.

Robotic versus laparoscopic intersphincteric resection for low rectal cancer: a systematic review and meta-analysis

PURPOSE

Few studies have compared robotic and laparoscopic intersphincteric resection (ISR) in rectal cancer. Therefore, we performed a meta-analysis of recently published studies to compare perioperative outcomes of ISR for the treatment of low rectal cancer.

METHODS

We performed a systematic literature search of the Ovid-Medline, Ovid-EMBASE, and Cochrane Central Register of Controlled Trials databases for studies comparing robotic and laparoscopic ISR in patients with low rectal cancer. Demographic and clinical data were extracted from articles that met the inclusion and exclusion criteria. Perioperative outcomes of interest included the rate of diverting stoma, open conversion rate, operation time, estimated blood loss, length of hospital stay, time to first flatus, and time to initiate the postoperative diet. Oncological outcomes included the number of retrieved lymph nodes, distal resection margin, proximal resection margin, circumferential resection margin, 3-year overall survival, 3-year disease-free survival, and local recurrence. Postoperative complications included overall complications, a Dindo-Clavien classification ≥ III, and anastomotic leakage. All outcomes were compared between the two groups.

RESULTS

We included 5 retrospective cohort studies with a total of 510 patients undergoing 273 (53.5%) robotic ISR procedures and 237 (46.5%) laparoscopic ISR procedures. The robotic ISR group lower conversion rate, lower blood loss, and longer operation times than the laparoscopic group. We also noted that fewer lymph nodes were harvested in the robotic ISR group; however, this difference was not statistically significant. Other outcomes were similar between the two groups.

CONCLUSIONS

Robotic and laparoscopic ISR showed comparable perioperative outcomes, functional outcomes, and 3-year oncologic outcomes; however, robotic ISR was associated with a lower conversion rate and less blood loss despite longer operation times compared to laparoscopic ISR. These findings suggest that robotic ISR maybe a safe and effective technique for treating low rectal cancer in selected patients. The potential oncologic and functional benefits of robotic ISR should be evaluated in larger randomized controlled trials.

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

Robotic total meso-rectal excision for rectal cancer: A systematic review following the publication of the ROLARR trial

AIM

To compare outcomes in patients undergoing rectal resection by robotic total meso-rectal excision (RTME) vs laparoscopic total meso-rectal excision (LTME).

METHODS

Standard medical electronic databases such as PubMed, MEDLINE, EMBASE and Scopus were searched to find relevant articles. The data retrieved from all types of included published comparative trials in patients undergoing RTME vs LTME was analysed using the principles of meta-analysis. The operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of TME. The summated outcome of continuous variables was expressed as standardized mean difference (SMD) and dichotomous data was presented in odds ratio (OR).

RESULTS

One RCT (ROLARR trial) and 27 other comparative studies reporting the non-oncological and oncological outcomes following RTME vs LTME were included in this review. In the random effects model analysis using the statistical software Review Manager 5.3, the RTME was associated with longer operation time (SMD, 0.46; 95%CI: 0.25, 0.67; z = 4.33; P = 0.0001), early passage of first flatus (P = 0.002), lower risk of conversion (P = 0.00001) and shorter hospitalization (P = 0.01). The statistical equivalence was seen between RTME and LTME for non-oncological variables like blood loss, morbidity, mortality and re-operation risk. The oncological variables such as recurrence (P = 0.96), number of harvested nodes (P = 0.49) and positive circumferential resection margin risk (P = 0.53) were also comparable in both groups. The length of distal resection margins was similar in both groups.

CONCLUSION

RTME is feasible and oncologically safe but failed to demonstrate any superiority over LTME for many surgical outcomes except early passage of flatus, lower risk of conversion and shorter hospitalization.

Meta-analysis of Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer

BACKGROUND/AIM

A meta-analysis was conducted to evaluate and compare the short- and long-term outcomes of robot-assisted (RAS) and conventional laparoscopic surgery (LAS) for rectal cancer.

MATERIALS AND METHODS

We searched MEDLINE for relevant papers published between 2010 and December 2017 by using specific search terms. We analyzed outcomes over short- and long-term periods.

RESULTS

We identified 23 papers reporting results that compared RAS for rectal cancer with LAS. Our meta-analysis included 4,348 patients with rectal cancer; 2,068 had undergone RAS, and 2,280 had undergone LAS. In the short- and long-term period, 27 and 7 outcome variables were examined, respectively. RAS for rectal cancer was significantly associated with a greater operative time and a lower conversion rate to open surgery in the short-term, and results in almost similar outcomes in the long-term, compared to LAS.

CONCLUSION

RAS may be an acceptable surgical treatment option compared to LAS for rectal cancer.

Robotic-Assisted versus Conventional Laparoscopic Approach for Rectal Cancer Surgery, First Egyptian Academic Center Experience, RCT

Background

Undoubtedly, robotic systems have largely penetrated the surgical field. For any new operative approach to become an accepted alternative to conventional methods, it must be proved safe and result in comparable outcomes. The purpose of this study is to compare the short-term operative as well as oncologic outcomes of robotic-assisted and laparoscopic rectal cancer resections.

Methods

This is a prospective randomized clinical trial conducted on patients with rectal cancer undergoing either robotic-assisted or laparoscopic surgery from April 2015 till February 2017. Patients' demographics, operative parameters, and short-term clinical and oncological outcomes were analyzed.

Results

Fifty-seven patients underwent permuted block randomization. Of these patients, 28 were assigned to undergo robotic-assisted rectal surgery and 29 to laparoscopic rectal surgery. After exclusion of 12 patients following randomization, 45 patients were included in the analysis. No significant differences exist between both groups in terms of age, gender, BMI, ASA score, clinical stage, and rate of receiving upfront chemoradiation. Estimated blood loss was evidently lower in the robotic than in the laparoscopic group (median: 200 versus 325 ml, p= 0.050). A significantly more distal margin is achieved in the robotic than in the laparoscopic group (median: 2.8 versus 1.8, p< 0.001). Although the circumferential radial margin (CRM) was complete in 18 patients (85.7%) in the robotic group in contrast to 15 patients (62.5%) in the laparoscopic group, it did not differ statistically (p=0.079). The overall postoperative complication rates were similar between the two groups.

Conclusion

To our knowledge, this is the first prospective randomized trial of robotic rectal surgery in the Middle East and Northern Africa region. Our early experience indicates that robotic rectal surgery is a feasible and safe procedure. It is not inferior to standard laparoscopy in terms of oncologic radicality and surgical complications. Organization number is IORG0003381. IRB number is IRB00004025.

Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study

PURPOSE

Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients.

METHODS

All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined.

RESULTS

A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033).

CONCLUSIONS

In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.

The short-term outcomes of robotic sphincter-preserving surgery for rectal cancer: comparison with open and laparoscopic surgery using a propensity score analysis

PURPOSE

The aim of this study is to clarify the short-term outcomes of robotic sphincter-preserving surgery for rectal cancer in a retrospective study.

METHODS

The short-term outcomes of robotic sphincter-preserving surgery (n = 130) were retrospectively compared to open (n = 234) and laparoscopic surgery (n = 318) by a propensity score analysis.

RESULTS

Robotic surgery was performed more frequently for patients with lower rectal cancer (55%) than open (30%, p < 0.0001) or laparoscopic surgery (36%, p < 0.0001). None of the robotic surgery cases were converted to open surgery. After propensity score matching, robotic surgery was found to be associated with a longer operation time (342 vs. 230 min, p < 0.0001) and less blood loss (7 vs. 420 mL, p < 0.0001) than open surgery. The overall complication rate of robotic surgery was lower than that of open surgery (13 vs. 28%, p = 0.032). Robotic surgery was associated with a lower incidence of surgical site infections (SSIs) than laparoscopic surgery (0 vs. 7%, p = 0.028). There were no cases of anastomotic leakage after robotic surgery. The circumferential resection margin was involved in 0.8% of the patients who underwent robotic surgery; the incidence did not differ among the treatment groups.

CONCLUSIONS

Although robotic surgery for rectal cancer was associated with a longer operation time, it was associated with a very low incidence of SSIs. The degree of safety was comparable to both open and laparoscopic surgery.

Robotic Colorectal Resection With and Without the Use of the New Da Vinci Table Motion: A Case-Matched Study

BACKGROUND

The da Vinci Table Motion (dVTM) is a new device that enables patients to be repositioned with instruments in place within the abdomen, and without undocking the robot. The present study was designed to compare operative and short-term outcomes of patients undergoing colorectal cancer surgery with the da Vinci Xi system, with or without use of the dVTM.

METHODS

Ten patients underwent robotic colorectal resection for cancer with the use of dVTM (Xi-dVTM group) between May 2015 and October 2015 at our center. The intraoperative and short-term clinical outcome were compared, using a case-control methodology (propensity scores approach to create 1:2 matched pairs), with a similar group of patients who underwent robotic colorectal surgery for cancer without the use of the dVTM device (Xi-only group).

RESULTS

Overall robotic operative time was shorter in the Xi-dVTM group ( P = .04). Operations were executed fully robotic in all Xi-dVTM cases, while 2 cases of the Xi-only group required conversion to open surgery because of bulky tumors and difficult exposure. Postoperative medical complications were higher in the Xi-only group ( P = .024).

CONCLUSIONS

In this preliminary experience, the use of the new dVTM with the da Vinci Xi in colorectal surgery, by overcoming the limitations of the fixed positions of the patient, enhanced the workflow and resulted in improved exposure of the operative field. Further studies with a greater number of patients are needed to confirm these benefits of the dVTM-da Vinci Xi robotically assisted colorectal surgery.

Participation of Colon and Rectal Fellows in Robotic Rectal Cancer Surgery: Effect on Surgical Outcomes

OBJECTIVES

To determine whether involvement of colon and rectal fellows has an effect on short-term surgical and oncological outcomes in robotic rectal cancer surgery.

PATIENTS AND METHODS

From a dataset of 263 robotic-assisted rectal cancer operations, 114 case-matched patients over a 5-year period (January 2010-December 2015) were included in the study. Patients who underwent resection with and without fellow involvement were compared. Cases were matched according to age, body mass index, neoadjuvant therapy, and tumor location. Intraoperative, postoperative, and pathological outcomes were compared between the 2 groups.

RESULTS

There was no difference in tumor grade, type of surgical procedure, presence of an anastomosis, or diverting stoma between groups. In addition, there was no difference in the incidence of intraoperative or postoperative complications between the 2 groups. Estimated blood loss was higher in the fellow group compared to the consultant group (mean difference of 70mL, p = 0.007). For pathological outcomes, there was no difference in surrogate oncological quality indicators, specifically margin positivity and lymph node yield, between the 2 groups. Furthermore, fellow involvement did not adversely affect operative time.

CONCLUSION

This study demonstrates that equivalent short-term surgical and oncological outcomes can be achieved with colorectal fellow participation in the field of robotic-assisted rectal cancer surgery.

Transanal Endoscopic and Transabdominal Robotic Total Mesorectal Excision for Mid-to-Low Rectal Cancer: Comparison of Short-term Postoperative and Oncologic Outcomes by Using a Case-Matched Analysis

Purpose

This study aimed to compare short-term postoperative and oncologic outcomes of a transanal endoscopic total mesorectal excision (TME) to those of a transabdominal robotic TME.

Methods

A total of 62 patients with rectal cancer underwent transanal (n = 26) or robotic (n = 36) TME between June 2013 and December 2014. After case-matching by tumor location and TNM stage, 45 patients were included for analysis. The median follow-up period was 21.3 months. Operative, histopathologic and postoperative outcomes and recurrences were analyzed.

Results

Patients younger than 60 years of age were more frequently observed in the robotic TME group (75.0% vs. 47.6%, P = 0.059), but tumor location, cT and cN category, and preoperative chemoradiotherapy were not different between the 2 groups. Estimated blood loss was greater in the transanal group (283 mL vs. 155 mL, P = 0.061); however, the operation time and the rate of a diverting ileostomy and subsequent ileostomy repair were not different between the groups. The proximal resection margin was longer in the transanal TME group (20.8 cm ± 16.0 cm, P = 0.030), but the distal resection margins, involvements of the circumferential resection margin, TME quality, numbers of retrieved lymph nodes, postoperative complications, including anastomotic leak and voiding difficulty, and recurrence rates for the 2 groups were not statistically different.

Conclusion

Transanal endoscopic and transabdominal robotic TME showed similar histopathologic and postoperative outcomes with the exception of the estimated blood loss and the proximal resection margin for a select group of patients.

Robot-assisted total mesorectal excision for rectal cancer: case-matched comparison of short-term surgical and functional outcomes between the da Vinci Xi and Si

BACKGROUND

Robotic rectal resection with da Vinci Si has some technical limitations, which could be overcome by the new da Vinci Xi. We compare short-term surgical and functional outcomes following robotic rectal resection with total mesorectal excision for cancer, with the da Vinci Xi (Xi-RobTME group) and the da Vinci Si (Si-RobTME group).

METHODS

The first consecutive 30 Xi-RobTME were compared with a Si-RobTME control group of 30 patients, selected using a one-to-one case-matched methodology from our prospectively collected Institutional database, comprising all cases performed between April 2010 and September 2016 by a single surgeon. Perioperative outcomes were compared. The impact of minimally invasive TME on autonomic function and quality of life was analyzed with specific questionnaires.

RESULTS

The docking and overall operative time were shorter in the Xi-RobTME group (p < 0.001 and p < 0.05 respectively). The mean differences of overall operative time and docking time were -33.8 min (95% CI -5.1 to -64.5) and -6 min (95% CI -4.1 to -7.9), respectively. A fully-robotic approach with complete splenic flexure mobilization was used in 30/30 (100%) of the Xi-RobTME cases and in 7/30 (23%) of the Si-RobTME group (p < 0.001). The hybrid approach in males and patients with BMI > 25 kg/m2 was necessary in ten patients (45 vs. 0%, p < 0.001) and in six patients (37 vs. 0%, p < 0.05), in the Si-RobTME and Xi-RobTME groups, respectively. There were no differences in conversion rate, mean hospital stay, pathological data, and in functional outcomes between the two groups before and at 1 year after surgery.

CONCLUSION

The technical advantages offered by the da Vinci Xi seem to be mainly associated with a shorter docking and operative time and with superior ability to perform a fully-robotic approach. Clinical and functional outcomes seem not to be improved, with the introduction of the new Xi platform.

Robotic-assisted total mesorectal excision with the single-docking technique for patients with rectal cancer

BACKGROUND

The robotic system has advantages of high-definition three-dimensional vision and articular instruments with high dexterity, allowing more precise dissection in the deep and narrow pelvic cavity.

METHODS

We enrolled 95 patients with stage I-III rectal cancer (adenocarcinoma) who underwent totally robotic-assisted total mesorectal excision (TME) with single-docking technique at a single institution between September 2013 and December 2016.

RESULTS

Of the 95 patients, 48 (50.5%) and 30 (31.6%) patients had lower and middle rectal cancers, respectively. Of the 75 (78.9%) patients undergoing preoperative concurrent chemoradiotherapy (CCRT), 27 (28.4%) exhibited pathologic complete response (pCR). Only four (4.2%) patients underwent abdominoperineal resection and the sphincter preservation rate was 95.8%. R0 resection was performed in 92 (96.8%) patients. Circumferential resection margin (CRM) and distal resection margin (DRM) were positive in 2 (2.1%) and 1 (1.1%) patients, respectively. The anastomotic leakage rate was 5.4% (5/95 patients). The overall complication rate was 17.9% (17/95 patients); most of them were mild. No 30-day hospital mortality occurred, and no patients required conversion to open surgery. In 92 patients undergoing R0 resection, 2-year overall survival was 94% and 2-year disease-free survival was 83%.

CONCLUSIONS

The results demonstrated that totally robotic-assisted TME with the single-docking technique is safe and feasible for patients with rectal cancer, with or without preoperative CCRT. Moreover, favorable pCR rate, R0 resection rate, CRM, DRM, sphincter preservation rate, and short-term oncological outcomes can be achieved by combining this approach with appropriate preoperative CCRT.

Laparoscopic and Robotic Surgeries for Patients With Colorectal Cancer Who Have Had a Previous Abdominal Surgery

PURPOSE

The impact of previous abdominal surgery (PAS) on surgical outcomes from laparoscopic and robot surgeries is inconclusive. This study aimed to investigate the impact of PAS on perioperative outcomes from laparoscopic and robotic colorectal surgeries.

METHODS

From March 2007 to February 2014, a total of 612 and 238 patients underwent laparoscopic and robotic surgeries, respectively. Patients were divided into 3 groups: those who did not have a PAS (NPAS), those who had a major PAS, and those who had a minor PAS. We further divided the patients so that our final groups for analysis were: patients with NPAS (n = 478), major PAS (n = 19), and minor PAS (n = 115) in the laparoscopy group, and patients with NPAS (n = 202) and minor PAS (n = 36) in the robotic surgery group.

RESULTS

In the laparoscopy group, no differences in the conversion rates between the 3 groups were noted (NPAS = 1.0% vs. major PAS = 0% vs. minor PAS = 1.7%, P = 0.701). In the robotic surgery group, the conversion rate did not differ between the NPAS group and the minor PAS group (1.0% vs. 2.8%, P = 0.390). Among the groups, neither the operation time, blood loss, days to soft diet, length of hospital stay, nor complication rate were affected by PAS.

CONCLUSION

PAS did not jeopardize the perioperative outcomes for either laparoscopic or robotic colorectal surgeries. Therefore, PAS should not be regarded as an absolute contraindication for minimally invasive colorectal surgeries.